Fertility in adenomyosis: surgery or IVF?

Adenomyosis is a chronic reproductive condition that impairs fertility and is characterized by endometrial tissue invading the myometrium. Despite advances in MRI and 3D ultrasound for diagnosis, there is still no consensus on optimal fertility management. The choice between uterus-sparing surgery and direct IVF, including the ideal timing for each approach, remains a subject of ongoing debate. This narrative review analyzed relevant studies retrieved from PubMed, Scopus, and Web of Science, focusing on uterine morphology, hormonal and surgical therapeutic responses, and IVF/ICSI outcomes in women with adenomyosis. Infertility in adenomyosis is associated with JZ remodeling, inflammation, hypercontractility, and impaired endometrial receptivity. Poor prognostic markers include JZ thickness ≥8.5 mm, uterine volume 90-130 mL, and MUSA direct features. These features are linked to lower live birth rates (aRR=0.62; 95% CI 0.43-0.88; P=0.007) and higher miscarriage risk (aRR=2.88; 95% CI 1.49-5.57; P=0.002), with larger uterine volume (>130 cm3) and thicker JZ significantly correlating with pregnancy failure and reduced cumulative live birth in Kaplan-Meier analyses. Assessment of JZ morphology, uterine volume, and MUSA features is crucial for individualized treatment planning in women with adenomyosis and infertility. Based on observational data, a pragmatic approach may include: 1) medical therapy with GnRH agonists for 3-6 cycles for uterine volumes 100-200 mL and JZmax 8.5-16 mm, followed by IVF; 2) consideration of uterus-sparing surgery for volumes >200 mL and JZmax >16 mm in highly selected patients, then IVF with an ultra-long protocol; and 3) direct IVF for volumes <100 mL and JZmax <8.5 mm, preferably using an ultra-long protocol with a freeze-all and HRT-FET strategy. These proposals are intended as a clinically oriented framework derived from current observational evidence rather than as formal guideline recommendations.